Documentary Investigates the Placebo Effect on Back Pain

Could relief for chronic back pain be as easy as taking a sugar pill? In the BBC documentary, “The Placebo Experiment: Can My Brain Cure My Body?” Dr. Michael Mosley sets out to investigate the power of the placebo effect.

Several studies have demonstrated complaints of lower back pain have risen dramatically in recent decades. Ranking 12th as a cause of disability in 1990,1 it’s now the leading cause of disability in nearly all high-income countries.2,3 As many as 8 in 10 adults will experience low back pain at some time in their life.4

Unfortunately, while the problem is fairly common worldwide, so is the mistreatment of the condition.5 In the U.S., more than 60 percent of people who see their physician for lower back pain are prescribed an opioid painkiller. This despite guidelines from the American College of Physicians which state prescription drugs should be used as a last resort.6

A series of papers published in The Lancet7 has highlighted the extent to which this mistreatment is contributing not only to further pain but also to opioid addiction. Considering the enormous risks of opioid treatment, it’s really important to keep our minds open to safer alternatives, provided they’re of any use.

The Power of Your Mind

To find out if fake pills and the power of your mind might be capable of providing effective pain relief, Mosley devised a novel experiment involving 100 patients, many of whom have spent years struggling with chronic back pain. Mosley and his team went to great lengths to create the impression that the patients were participating in a study of a brand-new and exceptionally effective pain drug.

Everything from the size, color and dosage of the pills and the label on the bottle, to the clinical environment and doctor-patient interface was based on previous placebo research. And, while the participants are told they will be randomly assigned to receive either the drug or a placebo, in reality, they’re all getting the placebo — a white and blue pill that contains nothing but rice powder.

At the same time, they also evaluated the potential benefits of simply having more time with an empathic doctor. So, while one group receives a standard consultation lasting no more than nine minutes and 22 seconds, which is the average consultation time for a general practitioner, the other group gets up to 30 minutes with the doctor. The experiment lasted for three weeks.

What did they find? As of Day 2 and 3, results were disappointing. None of the patients, all of whom were asked to keep a video diary log of how they felt each day, reported any kind of pain relief. However, by Week 2, many suddenly began reporting significant — and in some cases complete — pain relief.

Is the Placebo Effect Real?

Many are still under the mistaken impression that the placebo effect is somehow a “lie;” some kind of trick. However, modern research tools such as MRI scans reveal the effect is most definitely real, as it creates measurable changes in your brain.

For example, in trials involving placebos for pain relief, the participants’ brains release natural opioids that provide opioid-mediated pain control. So, the placebo effect is tapping into the same pain control centers as opioid drugs. Placebo trials on patients with Parkinson’s disease have revealed even this serious condition can be ameliorated with a dummy pill.

Lack of dopamine is one of the factors producing the symptoms of Parkinson’s, and brain scans show that when Parkinson’s patients are told they’re receiving an active medication, the dopamine levels in their brains increase, even when there’s no active ingredient in the pill. In fact, a placebo can release as much dopamine as amphetamines in a person with a healthy dopamine system.

Perhaps even more remarkable, studies have shown the placebo effect is at work in animals too. Rats have been found to experience placebo-induced pain relief,8,9 for example.

To demonstrate this, rats were injected with morphine two times, which preconditioned them to expect pain relief in conjunction with an injection. Then, when the morphine was traded for saline, as many as 40 percent of the rats responded with signs of pain relief, as if they’d been given morphine.

They’ve also found that when a placebo procedure is stressful or painful, such as an injection, it will impact the animal’s response.10 Hence, whenever stressful procedures are part of the study design, a control group of completely untreated animals should be included, in addition to the group getting the actual drug injected, and the group getting a placebo injection.

Epileptic dogs have also been shown to respond to placebo, actually experiencing a decrease in seizure frequency in response to sham drugs.11

Placebo Effect Also Plays a Big Role in the Effectiveness of Conventional Drugs

Some studies into the placebo effect have concluded that even many conventional treatments work because of the placebo effect. In one such study, the placebo effect was found to account for more than 50 percent of the therapeutic value of the migraine drug Maxalt.12 Lead author Ted Kaptchuk, professor of medicine at Harvard Medical School, explained:13

"This study untangled and reassembled the clinical effects of placebo and medication in a unique manner. Very few, if any, experiments have compared the effectiveness of medication under different degrees of information in a naturally recurring disease.

Our discovery showing that subjects' reports of pain were nearly identical when they were told that an active drug was a placebo as when they were told that a placebo was an active drug demonstrates that the placebo effect is an unacknowledged partner for powerful medications."

The Power of Expectations

Your expectation plays a significant role in the placebo effect, research14 shows. These expectations are influenced by medical rituals such as being forced to wait in a waiting room, being greeted by a doctor wearing a white lab coat and so on.

The words and body language your doctor uses also influence your expectations. Telling the patient that the treatment will relieve their symptoms produces a greater placebo effect than saying it “might” help. Other factors that influence a patient’s expectations include the size, color and price of the medication. For example:15,16

Capsules are more effective than tablets

Large capsules are more effective than small capsules

Expensive medications are more effective than inexpensive ones17

Red pills tend to be energizing while blue pills tend to be best for treating pain

Sham injections and sham acupuncture (which also uses needles) are more effective than placebo pills

In short, the placebo effect relies on your body’s own chemicals, released in response to or in accordance with your mental or emotional expectations or beliefs.

Research18 has also shown that your emotions and/or expectations can significantly influence the perceived intensity of pain. Positive expectations and emotions tend to minimize pain, while negative emotions such as fear tend to exacerbate it. This is an aspect of pain that has been exploited by torturers throughout human history.

Placebo Knee Surgery Just as Effective as Real Surgery

The placebo effect comes into play not only when you’re taking a pill but also during surgical procedures. One of the most dramatic examples of this was a knee surgery study19 published in the New England Journal of Medicine in 2002.

Not only does this double-blind, placebo-controlled, multicenter trial definitively prove the power of your mind in healing, it also reveals that most knee surgery for osteoarthritis is a waste of money.

The results of this study show the improvement people report after surgery is almost entirely due to the placebo effect. As noted by the authors, “In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic débridement were no better than those after a placebo procedure.”

A similar study20 published in 2013 also concluded that arthroscopic knee surgery for degenerative meniscal tears had no more benefit than sham surgery. This is a significant concession, as arthroscopic surgery on the meniscus is the most common orthopedic procedure in the U.S.

Here, they even excluded people with knee arthritis, as they tend not to benefit as much from meniscus surgery anyway, and the researchers wanted to ascertain if the surgery helps under "ideal circumstances."

These kinds of findings are well worth considering when weighing your treatment options. Remembering that your mind is the primary healer may help you find safer and less costly alternatives.

Placebo Surgery for Fractured Spines

A more extreme example involves sham back surgery. Vertebroplasty is a procedure in which a fractured spine is repaired by injecting surgical cement into the bone. However, one doctor became aware of a strange anomaly. Some patients, who for whatever reason received treatment on the wrong vertebrae, still received pain relief. So, he decided to undertake a placebo trial.

Some patients received the real procedure, and others received sham surgery. A total of 130 patients were included in this study. When the results were tallied, there was no statistical difference in the degree of pain relief between the real and the sham surgeries.

Even more importantly, there was no statistical difference in the improvement of physical function between the two. More than 1 million Americans have received vertebroplasty over the past couple of decades, yet it is no better than placebo!

“The Placebo Experiment” presents evidence from yet another sham surgery experiment. In 2012, Oxford University researchers investigated the effectiveness of acromioplasty, i.e., rotator cuff surgery, in which a small bone spur is removed from the shoulder.

In this trial, patients were randomly assigned to receive either real surgery or sham surgery in which an incision was made and then simply sewed back up without removing any of the bone. Here, again, the researchers found no difference between the real and the fake surgery. Both patient groups experienced the same rate of physical improvement and pain relief.

Can Placebo Effect be Used to Heal a Broken Heart?

In a second experiment, Mosley and his team set about to investigate whether the placebo effect might be used to help people recover after a relationship breakup. Heartbreak, he says, is essentially a form of depression, and if the placebo effect can help people recover from a broken heart, placebos could potentially benefit other types of depression as well.

Participants are first asked to view a photo of someone they feel very positively about. Next, they’re shown a photo of their ex. The participants rate how they feel about each on a scale of 1 through 5. They’re then given a nasal spray said to contain an analgesic designed to ease emotional pain. In reality, it’s just saltwater.

The same set of images are again shown, and in many cases, the participants were in fact feeling better about the partner who broke their heart. Some said they felt mildly happy.

This isn’t the first time the placebo effect has been shown to play a significant role in depression treatment. In fact, studies21,22 have repeatedly shown placebos are as effective as antidepressants in people with mild to moderate depression. Considering the long list of side effects associated with antidepressants, including worsening depression, it seems reasonable to conclude that a placebo would be a far preferable option to the real thing.

Placebo Can Work Even When You Know You’re Taking a Fake Pill

Ted Kaptchuk, professor of medicine at Harvard Medical School, is one of the leading researchers on the placebo effect. Normally, the placebo effect is studied by giving half of the test subjects the real treatment while the other gets a dummy pill, but neither of the groups is aware of what they’re getting.

Kaptchuk was curious what might happen if people knew they were receiving a placebo right from the start. So, in 2009, he launched the first open-label placebo trial,23 enrolling people diagnosed with irritable bowel syndrome (IBS).

Curiously, compared to those who received no treatment, nearly twice as many in the placebo group — all of whom knew they were taking a dummy pill — reported adequate symptom relief.

Overall, nearly 60 percent of the patients given a placebo pill (and, again, told they were receiving a placebo) reported adequate relief from IBS symptoms, compared to just 35 percent of those who received no treatment. Even more remarkable, the placebo group actually improved to a degree equal to that of two commonly prescribed IBS medications.

Harnessing the Healing Power of Placebo

At the three-week mark, 45 percent of the participants report feeling significant improvement. At this point, Mosley also reveals the truth: They’ve all been taking a placebo; there was no actual drug involved. All of these patients had previously been on powerful painkillers, yet simple rice powder capsules were now able to relieve their back pain.

The data also showed that of those whose medical appointment was of standard length, maxing out at nine minutes and 22 seconds, 38 percent reported significant improvement in pain. In the group who got up to half an hour with the physician, 51 percent significantly improved.

A final test remained though. Would they continue getting pain relief now that they knew they were taking a placebo? At the final follow-up at the end of Week 4, 70 percent of those who reported improvement at Week 3 and continued taking the pills did in fact continue to benefit — even though they knew they were taking a placebo.

This just goes to show that if you think you will benefit from a treatment, there’s a good chance you will, and this is all due to the placebo effect — whether the treatment consists of a “real” drug (or surgery) or not.